How do you avoid complications in LHR using Alexandrite? Do you still perform test shots in every patient ? How do you estimate skin color and energy levels? What's your treatment protocol if hypopigmentation should happen?

Avoiding complications in alexandrite LHR can be a tedious task, I do test each new candidate or patients that were exposed to the sun or artificial tanning... However, burns can appear as late as 24 hours post treatment and in different areas than those being tested... We managed to keep laser burns to a minimum but not to abolish them compleatly... In Order to do so, the energy level for each session should be considerably lower and the efficiency of the treatment is reduced a lot so many patients prefer to have better and faster results with the risk of minor burns.Alexandrite laser hipopigmentation differs from usual post inflamatory hypopigmentation due to the fact that the alexandrite light burns the melanin in the epidermal layer and the PIH appears to be very accentuated and extensive however... None of it is permanent !!! So it will get a lot better after controlled uv light exposure (this should be done 4-6 months after the burn heald compleatly and with medical supervision) i never had permanent hypogigmentation from the alexandrite laser but i treated these conditions by lightening the skin around the PIH or by microneedleing and melanocytic transfer... But again, not in the alexandrite laser cases.

There are no quick fixes. Post-inflammatory hypopigmentation is a long road. There are no guarantees that it will look the same as before, so don't make any promises. This is one of the risks you can't miss telling to your prospective laser hair removal patients.

With Alexandrite, I start with a pre-consult, pre & post discussion and begin on the low end of parameters. If I feel like there may be a reaction I send them home with post laser cream and follow up as indicated

It is always a good idea to perform a test spot at least 24 hrs before the laser treatment. Documentation is impt. Get a before and after pic of the tested area. Also, keep in mind that there are medications that may cause photo sensitivity.It can lead to undesired treatment complications such as dermatitis, hypo/hyper pigmentation, and burns.

Never treat outside the manufacturer's skin type/settings parameters. Skin typing should be done correctly.Take your time to assess your patients. Skin color changes throughout the year and throughout the treatment sessions. Reinforce health teachings. If your patient gets more than just a little sun exposure on the area you treated immediately after treatment, they can get hyperpigmentation. You should never get post-lesional hypopigmentation from laser treatment. If you are treating people with darker skin types you should consider the Nd:Yag laser.

When considering an Alexandrite laser for hair removal, take the following into consideration:

1- if treating darker skin types, you MUST have 18mm spot size, and a high average power. You CAN safely treat darker skin types with Alexandrite if you have a long enough pulse width, and a large enough spot size. The EpiCare LPX and Duo, for example, have 100W overall average power, and 18mm spot sizes. The next best would be the GentleLase with it's 18mm spot size, but terrible overall average power (I believe 65W or 85W).

2- A directional sliding rule of thumb: 690nm (Ruby Laser) is the most painless yet still effective on lighter skin with lighter hair... 755nm is comfortable on lighter skin, and more effective than Ruby on darker hair. 1064nm is most painful on lighter skin, less effective on light hair, less painful on dark skin, and more effective on darker hair.

3- IPL and Diode are not fully monochromatic, and the hand pieces don't offer the best targeting. Be mindful of the above sliding scale should you choose IPL or Diode.

We perform test shots on every new client prior to treatment the first time. It is important to use enough energy to kill the hair root so that you achieve perifollicular edema, diffused erethyma, and the smell of burning hair. However, IF the patient complains of stinging after just a few minutes you are using too much energy for the skin type and the patient will get hyperpigmentation or a burn. If the discomfort goes away almost instantly, you are using the correct setting. If there is no discomfort, you are not applying enough energy to kill hair.

Thank you for your detailed responses. I see that pain is a very important parameter for avoiding alexandrite burns and you have make a very good investigation. I have a DermaTone device for estimating skin color but not used to frequently. I plan to make a test procedure for risky skin types. How you perform the test shots and when you control the patient after the shot ? Normally i control the patients after 2 days.

I strongly agree. It is always a good idea to perform a test spot at least 24 hrs before the laser treatment with before and after pic of the tested area. Also, keep in mind that there are medications that may cause photo sensitivity.It can lead to undesired treatment complications such as dermatitis, hypo/hyper pigmentation, and burns.

I schedule test spot for anyone fitz IV and beyond with yag. With alex I start with a pre treat consult, discuss pre & post discussion and begin on the low end of parameters. If I feel like there may be a reaction I send them home with post laser cream and follow up as indicated.

I have an Candela Mini GentleLase. I am having issue with efficacy removing and even sometimes stimulating hair growth in particular areas. Men's backs is the major one, and also females faces. This predominantly occurs with High Fitz III to Fitz IV clients. Anyone had a similar problem with the darker skin types and stimulation of hair growth? Also in treating men's backs I am finding that about 30% of my male clients are resistive to treatment on their back areas. Chest is usually ok. - See more at: http://medicalspamd.com/ipl-laser-treatments/post/1886019?lastPage=true#sthash.dEfanjHm.dpuf

I also agree that you should test the tissue at low and medium parameters prior to a full treatment. However, you may want to consider waiting more than 24 hours. I have made a client wait 3 to 5 days to determine post test reactions as it gives the area time to rest and react. I also agree that a thorough consultation of skin type is critical. In addition, prior to each treatment the individual should be asked (again) when they last had both natural an unnatural sun exposure (including tanning lotions), any medication changes at each treatment are critical in achieving positive results long term.

I have been in practice since 2001. We use the Candela GentleLASE Plus and Candela GentleYag lasers. When we first started we had clients wait for 24 to 48 hours after spot treatment. After about a month it became apparent that waiting was very generally NOT necessary. I found that any adverse reaction will show up in 15-20 minutes on Fitzpatrick types 1-3. The very best clue is whether or not a client has continued stinging. As a general rule, on the Candela with an 18mm spot size, most people fall between 16 and 18 joules unless the hair is very dark and thick. I start with 16 joules on people with brown to dark brown hair. A "great" indicator of efficacy is to see the hair turn from brown to dark brown or black (in other words, the hair in the follicle appears to be burned, ashey). If there is enough stubble, I perform what we call a "slide" test wherein I use a pair of o1 sharp pointed tweezers to grad onto the hair stubble and gently tug on the hair (no jerking). If the hair slides out gently, the root was killed. I like to test 6 to 8 hairs. If I see 80% of the hairs without bulbs, the setting is good. If they do not slide out readily, I go up on step until I see burned hair and the slide test is effective.

Wow marti! never heard of the slide test. it's good to know. I have the GentleMax and so far, no problems. I usually start at the low end of the suggested joules and work up. The instructor for Candela was NOT GOOD. Thanks for the info.

Sometimes hairs that are not in the anagen growth phase can slide out when treated. I have found that most people will not tolerate pain and therefore the method of determining easily removed hair after testing at varying settings is not inefficient for these patients. This is why multiple treatments and manufacturer recommended settings are an important place to start. However, using the hair to determine energy levels after observing how it responds to various settings is a great method. I suggest pulling a hair or two out and testing them directly - not attached to the patient - to save the person unnecessary discomfort.

Testing a hair in-vivo ( in the skin ) is better than pulling and testing it out the skin. Because of lasers reflection properties energy levels can be different. Some of the energy absorbed directly by the skin and adjacent structures like sebase glands etc. I have heard this test also while performing electroepilation, right ? If you damaged the hair follicle badly while not harming the patient you are on the right way. One thing to remember is some hairs can be in telogen phase and they can easy pull off . Before the laser test shot you can test the hairs in the test spot area while they are telogen or not.